Ethics case study
Checking up on immigrants: a job for physicians?
- Previously published ethics case studies are available online.
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This is the 16th in a series of case studies with commentaries developed by the ACP Ethics and Human Rights Committee. The series elaborates on controversial or subtle aspects of issues not addressed in detail in the ACP "Ethics Manual" or in other position statements.
California internist Frank James has just concluded an examination of a new patient, 33-year-old Joseph Lopez. Mr. Lopez complains of fever and has also been experiencing night sweats and weight loss for the past month or so. "Are you coughing?" asks Dr. James. "Yes," the patient responds. When Dr. James asks if anyone else in the family is coughing or seems sick, Mr. Lopez falls silent and looks scared. "I smoke," he says. "Coughing from smoke."
Dr. James doesn't agree. He suspects tuberculosis and believes Mr. Lopez needs evaluation for the possibility of a co-infection with HIV. He asks Mr. Lopez if he has had a tuberculin skin test before; the patient says he doesn't think so. Dr. James performs the skin test. He tells Mr. Lopez he wants him to go to Memorial General Hospital for more tests, and orders a sputum culture and chest X-ray. He learns that the patient has no insurance.
"No hospital," says Mr. Lopez in broken English. "187." Dr. James understands Mr. Lopez to be referencing California's Proposition 187, which restricts non-emergency medical care for undocumented immigrants and requires that they be reported to the state and the U.S. Immigration and Naturalization Service if they seek care at a "publicly-funded health care facility."
"Are you in this country legally?" Dr. James asks the patient, anticipating he will say no given that he had not previously had a skin test. Instead, there is no response. "Well," Dr. James continues, "Proposition 187 has been tied up in the courts. No patients are having their immigration status checked, and no one is being reported to INS. I don't think we need to worry about 187 right now." "No hospital," Mr. Lopez repeats. Dr. James says he will find out more about Proposition 187, and emphasizes the importance of the hospital tests. He asks the patient to have the receptionist schedule another appointment for next week.
Later that day, Dr. James discovers that Mr. Lopez did not make a follow-up appointment. The patient paid cash for that day's visit and when asked about follow-up, he responded "187."
The case presented here describes a man who clearly needs medical attention, but who fears that he will be thrown out of the country if he seeks care. It shows how laws like Proposition 187 might harm patients by encouraging them to avoid health care even when they have curable illnesses.
Proposition 187 has the potential to hurt the health of individuals, but it may also harm the doctor-patient relationship. Patients need to know that they can trust their physician to look out for their interests and to maintain confidentiality with few exceptions. This trust cannot be maintained if patients come to regard their physicians as police. This holds true for undocumented immigrants, who would fear being expelled from the country as a result of seeking care, and for legal immigrants, who could find physicians hesitant to provide care to patients they fear might be undocumented immigrants.
California's Proposition 187 was passed in the midst of a large state budget deficit that led to reductions in state Medicaid funding and pressure to reduce health care and other spending for undocumented aliens. Of all states, California has sustained the largest burden of costs for the provision of health care to undocumented aliens. In 1993, the state spent an estimated $389 million out of $731 million of total state and federal Medicaid funds on emergency care for undocumented aliens. (The next closest states—New York, Illinois, and Texas—spent $23, $19.7, and $19.4 million respectively. ) This level of spending contributed to the vote tally; 59% of California residents voted to pass Proposition 187.
The California Medical Association and the AMA opposed Proposition 187 on the grounds that it would endanger public health and violate the confidentiality of the doctor-patient relationship. This raises an important question: Who should determine professional norms, medical professionals or society as a whole?
Tensions exist between the medical profession's need to establish ethical standards and society's need to regulate the profession. Since the time of Hippocrates, physicians may have taken the lead in creating ethics codes that guide physician behavior. But legal standards also have improved the medical profession's moral standards; the law, for instance, was instrumental in improving standards of informed consent in medical practice.
In many cases, however, society and the medical profession have different ideas about what physicians ought to do. Debates about whether physicians should assist in patient suicide, be involved in capital punishment or discuss options like abortion illustrate the tension between societal and medical views of physicians' professional duties.
Proposition 187 is the latest example of this tension. The public has asked health care providers to collect and disclose information about patients that has nothing to do with the individual's medical status. The vulnerability of the sick is used as a tool for furthering a completely unrelated goal: finding illegal aliens and expelling them from the country.
Checking the immigration status of patients is not an appropriate function for physicians and other health care providers, and is an interference with the doctor-patient relationship. Technically, under Proposition 187 publicly funded health care facilities, not physicians like Dr. James, have to report undocumented aliens. Publicly funded health care facilities are defined as those "to which persons are admitted for a 24-hour stay or longer." But while Dr. James can treat and need not report Mr. Lopez, the patient also needs hospital care.
There is also concern that facilities may check the immigration status of legal immigrants based on their ethnicity. This could lead to discrimination, with immigrants from Europe receiving care and immigrants from Latin American or other countries receiving scrutiny. It is hard to imagine any of this improving the doctor-patient relationship.
In addition, the case shows how Proposition 187 might harm the public health, because the patients avoiding care may be infected with a disease like tuberculosis and spread it throughout the community. This would clearly interfere with the profession's mandate that "physicians must fulfill the profession's collective responsibility to be advocates for the health of the public" as well as that of individual patients. (2) The law also violates the tenet that a physician may not discriminate against a class or category of patients by denying appropriate care. (2, 3)
While it is true that physicians are legally required to report all cases of tuberculosis to the public health department, this breach of confidentiality is acceptable because it serves the public health. But physicians cannot report cases of tuberculosis that they do not see. And if people with tuberculosis refuse to see a physician, the spread of tuberculosis will increase, harming public health.
California voters have passed a law that asks physicians to do things that contradict their most basic duties to protect the individual patient's and public health. Society has helped improve the medical profession in many ways, but in the case of Proposition 187, physicians could be faced with a law that is harmful to the public health and the ethics of the profession. (Proposition 187 remains blocked by court order until litigation is resolved.)
With the privilege of practicing medicine comes responsibility. Physicians must remember that they "are morally as well as legally accountable, and the two may not be concordant. ... Physicians must keep in mind the distinctions and potential conflicts between legal and ethical obligations when making clinical decisions … " (2) Sometimes this leads to conscientious objection by an individual against societal mandates; sometimes, to civil disobedience.
Until the status of Proposition 187 is resolved, and even afterwards, physicians should do everything they can to take care of patients, regardless of whether they are legal or illegal immigrants. If Proposition 187 goes into effect, physicians and other health professionals will have a more difficult choice of deciding whether or not they want to abide by a law that violates their moral duties.
Acknowledgments: The Ethics and Human Rights Committee would like to thank Lois Snyder, JD, and Bernard Lo, FACP, authors of this case history; and Peter A. Ubel, ACP Member, author of the commentary.
1. Urban Institute. Fiscal Impacts of Undocumented Aliens. Washington, D.C.: Urban Institute, September, 1994.
2. American Collge of Physicians Ethics Manual, 3rd edition. Ann Intern Med.1992;117:947-960.
3. Snyder L, Weiner J. Ethics and Medicaid patients. In: Snyder L, ed. Ethical Choices: Case Studies for Medical Practice. Philadelphia, Pa.: American College of Physicians; 1996.
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